Beyond these walls: reaching rural/remote people with high-quality - - PowerPoint PPT Presentation
Beyond these walls: reaching rural/remote people with high-quality GIM care AMY HENDRICKS, FRCPC INTERNIST, ANTIGONISH, NS October 2018, CSIM Disclosures I have no commercial interests related to travel clinics or non face-to-face care.
reaching rural/remote people with high-quality GIM care
AMY HENDRICKS, FRCPC INTERNIST, ANTIGONISH, NS
October 2018, CSIM
clinics or non face-to-face care.
David – 66 yo man with AI, 3VD, RA, COPD Echo in August – LV 65mm, Simpson’s 37%, severe AI Referred by GP (in Port Hawkesbury) to Cardiology Seen in Inverness travel clinic Sept 19th. Feels fine. Mild edema. Note to GP Presented to Inverness two weeks later – trop up, pulm edema GP in PH calls me – please get him where he needs to be
Call to MRP in Inverness to clarify situation Filled out cath referral form to send to Hx Patient awaited transfer in Inverness
Safety ensured by relationships with both sites Direct knowledge of local circumstances Internist as bridge (community sites<-> tertiary site) The travel clinic made all the difference
individuals (and populations) living far from the usual practice setting
patient travel, and propose less costly alternatives
geographically distributed practice designed to meet the needs of patients and other care providers
Tuttle et al. Australian Journal of Rural Health, 2016
Curiosity Altruism Accessibility Creativity
transmission of data to the provider
remote consultations between providers (e.g. teledermatology)
Focus on real-time clinical encounters between doc and pt; and population care
68-year-old retired nurse living with her frail husband Presents with dyspnea and fatigue; LVEF 25-30% DM on insulin, CKD (creat 130) Lives 5 hours from Halifax, 2 hours from Antigonish She needs: cath, medication titration, CHIM She has: an NP in community, internist in Antigonish EST and CHIM offered locally
Parking: $2 Walk time: 5 minutes Distance: 135 km
Parking: $6-10 Walk time: 15 minutes Distance: 345 km
Monthly med titration: NP on the phone, internist in Antigonish Weight, BP, creat, K, and physical exam by NP *would telehealth change clinical decisions? Scheduled, remunerated and documented via letter back to NP 15-minute slot, 5-minutes on the phone Internist travel to Inverness (q6 weeks) -> EST on site CHIM in community, 3 times per week
EMR Schedule 11:00 Paul MacDonald 11:40 Greg MacDougall 12:00 Annie Gorgan Phone F/U Phone NP 902-867- 4635 1:00 Donna Trump Billing Sheet Code To do 11:00 PM E-001 Office 2 months 15 min 11:40 GM Cx f/u No f/u 12:00 AG Phone f/u 12:06-12:13 EST Inv
... And what is that treadmill doing in Inverness?
Previous regular services in Northside from CBRH internists NS recruited a GIM; RB explored Inverness (watershed) Adequate MD resources in CBRH; reached out to GP leads
Inverness Cheticamp Sydney
Convenient and efficient to see patients in home setting:
His secretary can get her work done for a day No distractions Ability to interact with referring MDs face-to-face
Curiosity re. local circumstances – the call from Cheticamp now occurs within a clearer context
Demo machine in Dec 1999 after regular clinics established 16 ESTs during TC with visiting Sydney tech Put on budget, then scrapped by district Hospital Foundation funded purchase Q6wks 20 ESTs for 18 years – nearly 3000 ESTs Other added services: Pacemaker checks (interrogators from 2 manufacturers donated) Community cardiac/pulmonary rehab and ortho prehab
Don’t fill out a form; shake a hand Hospital foundations are key Services are highly desired if facilities are at risk Staffing may be different (LPN, RT for EST’s) Your commitment may be richly rewarded Relational, not political approach e.g. echo at SMRH, cardioresp donation CHIM in Inverness – RB’s ongoing support (gratis) Keep it fun!
Tuberculosis Rounds
2-4 weeks in the hospital 6-18 months total treatment, in community There’s a lot that can happen in 18 months! How can we be rapidly responsive to the patient – and the nurse on the ground?
Dialysis telehealth Lung cancer work-up Oncology telehealth INSPIRED (COPD home mgt) Palliative care rounds Diabetes teams Cardiac rehab Heart function clinic support
Travel/ outreach clinic (the specialist moves towards the patient) Non face-to-face care (the specialist and patient have clinical encounters that do not involve travel) *real-time encounters, for our purposes The tyranny of distance can cause poor access, lower frequency of follow-up, high patient costs, less guideline-adherent care, more fragmentation
From the literature: 4 models (Williams, 1981)
but care delivered through PCP)
visiting services)
Urban non-disadvantaged: more data, lower benefit Urban disadvantaged Rural non-disadvantaged Rural disadvantaged (increased specialist utilization by up to 390%, with reduced hospital-based costs – Gruen, 1993-1999, surgical pts in remote Australia)
Oncology rural outreach (US) for BrCA-> more guideline- consistent care Howe et al. Cancer Causes Control 1992 Joint ortho/GP consultation-> fewer diagnostic and lab tests (Dutch) Vierhout et al. Lancet 1995 Multifaceted interventions-> lower hospitalization rate and improved clinical outcomes (psychiatry)
Virtually no data for IM-specific travel clinics in 2010 Cochrane review
IM-specific data are largely lacking; locally distinct Comparative data on overall system/patient costs Analysis of cons of travel/outreach including:
practice
equipment or information systems The critical mass of patients, or critical distance, to make outreach worthwhile (?by what measure?)
Reliability is key. Don’t have a threshold, even if you’re FFS Expansion of your procedural practice is a real possibility Clerical support, space, and computer access are essential Nurture your passions, and the locals will support them
Telehealth:
*psychiatry (>50% in Canada), nephrology, oncology
*Telederm, radiology, ophthalmology, wound care
*chronic disease management from the home setting
IM tools: a telephone, labs, +/- a colleague history is still essential -> no store-and-forward
As an expert to a population of patients/providers? As a diligent doc preventing travel day-to-day? By stepping out of the office into another setting?
National cross-sectional study of Australian specialists, 2017 567 specialists providing rural/remote outreach services (Sullivan et al., Human Resources for Health (2017)15:3) Self-reported reasons for participating in outreach Salaried vs. FFS Inner regional vs. Outer regional/Remote outreach Metropolitan vs. rural specialists
19% of specialists providing outreach clinical services
42-44% of urologists/renal 30-33% of oncologists, ENT 13% of subspecialist surgeons 21-22% of internists
26% of travelling specialists were required to do outreach
40% if salaried 14% if FFS
O’Sullivan et al. Human Resources for Health (2017) 15:3
Growing my practice the major impetus for outreach (especially among salaried specialists)
Managing more complex conditions and maintaining a connection with a region were also significant motivations for outreach Providing care for disadvantaged people and supporting rural staff were relatively minor factors
*Salaried structure *Clear expectations, long history *All administration looked after (flights, accommodations, bookings, transcription) *Clear hospital mandate (financial and altruistic) *Regular schedule of contractually obligated clinics *Social events with local staff physicians
Local responsibilities vs. your responsibilities for: triaging consults booking patients, notifying them, reminders transcription space, equipment follow-up care booking investigations An individual vs. a shared commitment
will you see each others’ follow-ups? do you have a similar practice pattern? how will you set the schedule?
Space – examining table, BP cuff Local results – paper or computer chart access Clerical – someone to register patients Local requisitions for labs, DI, cardiodiagnostics, PFTs
Remuneration for travel and accommodations Payment for travel time (good luck) Added services (e.g. education for support staff, local docs) Fancy stuff (pacemaker interrogators, treadmill, POCUS)
Higher efficiency in travel clinics (start early, shorter appts)
accommodations costs NFTF fee codes in NS: With PCP (requires consultation letter) Direct to patient (can be follow-up) Telehealth
Consider the route of next follow-up at the end of each appt: Distance, cost, patient preference What you really need for the next clinical decision(s)
Is it difficult for you to come to my office every couple
Can you have your blood pressure/weight checked in your community? Would you prefer that our next appointment be a phone call (booked, documented)?
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